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BRING YOUR INSURANCE CARD

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BRING YOUR INSURANCE CARD Powered By Docstoc
					                                    F.I.T. Health Services
                               Room A402, Phone (212) 217-4190


                   PLEASE ARRIVE ON TIME.
       ALL PAPERS MUST BE COMPLETED BEFORE ARRIVAL.

                  CANCELLATION OF WOMEN’S CLINIC APPOINTMENTS

      PLEASE CALL AT LEAST 24 HOURS IN ADVANCE IN CASE OF CANCELLATION.
             LATE ARRIVAL WILL BE RESCHEDULED ONLY ONE (1) TIME.

The Women’s Clinic is a very popular clinic and appointments are at a premium; therefore, the Health
Services has instituted the following policy:

       A student who needs to cancel a Women’s Clinic appointment must notify the Health
       Services at least 24 hours in advance. The only exception to this rule will be for an
       extreme emergency, which must be individually discussed with the appropriate Health
       Services provider. Failure to comply with these rules will result in losing your privilege
       to use the Women’s Clinic.


PLEASE READ THIS BEFORE COMING TO YOUR WOMEN’S CLINIC APPOINTMENT

   1. BE ON TIME. If you are late, you will have to reschedule your appointment and we will only
      do that once.

   2. Know the date of your last menstrual period (LMP). The day it began is the first day of your last
      period – this is the beginning of your last cycle.

   3. Come to the Health Services with your forms filled out.

   4. If you have any questions, call the Health Services during regular hours at (212) 217-4190.


                               *** VERY IMPORTANT ***
For 24 hours prior to the test – DO NOT: 1) douche; 2) have sex; or 3) use vaginal medications.


                                             Attention:
                          If you do not have the insurance provided by F.I.T.,
                   BRING YOUR INSURANCE CARD
                             Fashion Institute of Technology
                                 HEALTH SERVICES

                 MEDICAL CONFIDENTIALITY PROTOCOL
                                      Please Print


                                                            Date: ______________________________


       IN KEEPING WITH MEDICAL CONFIDENTIALITY PROTOCOL, WE WOULD LIKE YOU TO
FILL IN THE FOLLOWING SHOULD WE NEED TO CONTACT YOU REGARDING YOUR LAB
RESULTS.


     1. STUDENT’S NAME:      ____________________________________________
        SS# / STUDENT ID#:   ____________________________________________


     2. DURING SCHOOL:
                   ______    MAIL:     __________________________________
                                                        Address

                                       __________________________________
                                       __________________________________
                                                     City, State, Zip

                   ______    PHONE:    __________________________________

                   ______    EMAIL:    __________________________________


     3. DURING BREAKS:
                   ______    MAIL:     __________________________________
                                                        Address

                                       __________________________________
                                       __________________________________
                                                     City, State, Zip

                   ______    PHONE:    __________________________________

                   ______    EMAIL:    __________________________________




                                         SIGNATURE: ____________________________________
                                                F.I.T. Health Services
                                           Annual Gynecological Examination

Date:       _______________________________

Name:       ____________________________________________               SS#:         _____________________________       Age: __________

Medications:        ______________________________________             Allergies:      ___________________________________________

Past Medical History:       ______________________________             Past Surgical History: _____________________________________


FAMILY HISTORY
(Please indicate who has the following: i.e. mother, father, and/or sibling)
Cancer: ____________________________________________                   Diabetes: ______________________________________________
High Blood Pressure: _________________________________                 Heart Disease: __________________________________________
Other:      ____________________________________________


GYNECOLOGICAL HISTORY
First day of last menstrual period:      _____ / _____ / _______       Last Pap Smear:      _____ / _____ / _______
History of Abnormal Pap?           Yes  No            If yes, when? _____ / _____ / _______       Treatment follow-up?     Yes  No
Are you sexually active?           Yes  No            With (check one):       Men        Women          Both
Pain during intercourse?           Yes  No
Anal intercourse?                  Yes  No            Current birth control method: ___________________________________________

Have you ever been pregnant?           Yes  No        # of pregnancies       _________            # of miscarriages   _________
                                                        # of children _________                     # of terminations   _________
Do you douche?                     Yes  No
What do you do to protect yourself from STD’s and HIV? ________________________________________________________________
Any current gynecological complaints (abnormal discharge, odor, pain, lesions, itching, painful/heavy bleeding, breast pain, breast
discharges, or breast changes): _____________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________


SOCIAL HISTORY
Tobacco use:                    No       Yes     _____________       How much?       ________________       How many years? ________

Alcohol use:                    No       Yes     _______________________________________________________________________

Drug use:                       No       Yes     _______________________________________________________________________

Domestic Violence:              No       Yes     _______________________________________________________________________

Rape:                           No       Yes     _______________________________________________________________________

Incest:                         No       Yes     _______________________________________________________________________

Regular exercise:               No       Yes     _______________________________________________________________________




                                                                  Page 1 of 3
                                            F.I.T. Health Services
                                       Annual Gynecological Examination
             THE REMAINDER OF THIS FORM IS FOR THE USE OF THE HEALTH CARE PROVIDER


Name: ____________________________________________                                 Date:   ______________________________

 Above history reviewed with patient
 Teaching provided regarding need for regular paps, STD prevention
 Teaching regarding BC method if newly starting
 No contraindications for oral contraceptives/patch, or ring
 ACHES discussed, warning signs given

BP: _____________         HR: _____________          Ht: _____________       Wt: _____________



REVIEW OF SYSTEMS:              No changes since _____ / _____ / _______

1.   General       Negative       Wt. Loss       Wt. Gain       Fever                   Fatigue
                   Other _______________________________________
2.   Eyes          Negative          Vision Chg        Glasses/lenses  Other _______________________________________
3.   ENT           Negative          Ulcers            Sinusitis         Tinnitus       Headache
4.   CV            Negative       Orthopnea      Chest pain     DOE                     Edema              Palpitation
                   Other _______________________________________
5.   Resp          Negative       Wheezing       Hemoptysis     SOB                     Cough
                   Other _______________________________________
6.   GI            Negative       Diarrhea       Bloody Stool            N/V            Constipation       Pain
                   Other _______________________________
7.   GU            Negative          Hematuria         Dysuria           Urgency        Freq
8.   Gyn           Negative          Abn. Bldng        Dyspareunia       Irregular Periods         Menstrual problems
                   Spotting          Pelvic Pain       Discharge         Itching           Other _______________________
9.   MS            Negative          Weakness          Other _______________________________________
10. Skin           Negative          Rash              Ulcers            Other _______________________________________
11. Breast         Negative          Mastalgia         Discharge         Masses         Other _______________________
12. Neuro          Negative       Syncope        Seizures       Numbness                Trouble walking
                   Other _______________________________________
13. Psych          Negative          Depression        Crying            Anxiety        Other _______________________
14. Endo           Negative       Diabetes       Hypothyroid  Hyperthyroid              Hot flashes
                   Other _______________________________________
15. H/L            Negative          Bruises           Bleeding          Adenopathy     Other _______________________




                                                            Page 2 of 3
                                              F.I.T. Health Service
                                        Annual Gynecological Examination

Name: ____________________________________________                         Date:   ______________________________

LUNGS              Normal Breath Sound          Abnormal ________________________________________________________
HEART              Normal Rate/Rhythm           Abnormal ________________________________________________________
THYROID            Normal                       Abnormal ________________________________________________________
BREAST             R – Normal      L - Normal     Abnormal       Axillary Adenopathy    Self-breast exam taught



                                          o             o



ABDOMEN            Normal        Abnormal ___________________________________________________________________
VULVA              Normal        Abnormal ___________________________________________________________________
VAGINA             Normal        Abnormal ______________________  Abnormal Discharge _______________________
                   Wetmount ______________________________________  Not indicated history
CERVIX             Normal        Abnormal       Discharge ___________  Lesions _____________  CMT ________




UTERUS             Normal           Abnormal ______________________  Position _________________________________
RECTAL             Not done         Normal        External Condyloma     Other _______________________________
ADNEXA             Normal           Abnormal ___________________________________________________________________


Other physical findings based on history/ROS:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________


A: ____________________________________________________________________________________________________________
________________________________________________________________________________________________________________

P: _____________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________


 Pap done         GC/Chlamydia swab done


Provider Signature: _________________________________________________   MD NP


                                                       Page 3 of 3

				
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posted:7/31/2011
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